1. Increasing Collaboration Around Social Determinants of Health
MDwise
       Increasing Collaboration Around Social Determinants of Health

2. MDwise Overview – Delivery System Model
Delivery System Flow Chart
BH is self referral – no DS limitations

3. Final determination made by staff RN’s.
Medically Frail, cont.
FSSA requires the MCEs to use Milliman’s Medical Underwriting Guidelines for the purpose of evaluating frailty.
Members are considered frail if they meet the following debit point thresholds:
150 debit points for indicated medical conditions
75 debit points for indicated behavioral health conditions
75 debit points for indicated substance abuse conditions
150 debit points in total across all categories
Final determination made by staff RN’s.

4. Medically Frail Overview
The program is designed to provide extra coverage for HIP members who meet one of the following criteria:
A disabling mental disorder;
A chronic substance abuse disorder;
A serious and complex medical condition(s);
A physical, intellectual, or developmental disability that significantly impairs the individuals’ ability to perform one or more activities of daily living; or
A disability determination based on Social Security Administration criteria.
Members can self referral or referred by the CMHC.

5. Medically Frail Referral Process
MDwise staff request records from providers to determine frailty status
MDwise Medically Frail fax/phone number or
We are available to participate in clinical staffing's to review members and/or develop the most efficient referral process for our members.
If you remember nothing else, these things will help you:
Medically frail status is only for fully eligible HIP members.
Medically frail confirmation puts members on State Plan and that means extra benefits (transportation, dental, MRO).

6. Influencing members facing social determinants
Transition Home Visits - helping bridge the gap for members with immediate needs after hospitalization.
Implementing the new Federal Lifeline Assistance Program
Free Android Smart phone for those that qualify or the ability to use their own phone.
Homelessness- MDwise is involved with coordinating services and projects with several other community groups
IN Data Integration Project
CHIP Coalition for Homelessness Intervention and Prevention
CSH Corporation for Supportive Housing